The phrase “will continue to monitor” (WCTM) is a common shortcut in nursing documentation, but it significantly compromises the integrity of the patient’s medical record. This generic statement is vague and fails to communicate the concrete details of ongoing care. WCTM is discouraged because it is non-specific, does not reflect clinical reasoning, and potentially undermines the legal defense of the nurse and the healthcare facility. This practice creates gaps in the continuity of care and obscures evidence of a nurse’s professional actions. This article explores the dangers of this documentation and provides actionable alternatives.
Why Vague Language Fails Clinical Communication
The primary function of nursing documentation is to communicate a patient’s status and the care provided to the entire interprofessional healthcare team. Writing “will continue to monitor” bypasses this requirement by failing to specify the exact parameters or frequency of observations. A subsequent caregiver reading that note cannot discern if the nurse was watching for a change in pain level, monitoring for a specific medication side effect, or tracking a subtle trend in a respiratory rate.
Effective clinical communication demands objective, descriptive language that clearly depicts the patient’s condition and the nurse’s thought process. A vague statement like WCTM offers no measurable data, which is necessary for evidence-based practice and accurate evaluation of interventions. For example, if a patient receives an intravenous diuretic, the nurse must document hourly urine output and electrolyte levels, not just a general intention to monitor. The absence of specific parameters prevents other clinicians from quickly identifying subtle changes in a patient’s status.
The Documentation Link to Legal Liability
The patient’s electronic health record is a legal document. In a malpractice lawsuit, what is not charted specifically is often presumed not to have been done. Defense lawyers dislike “will continue to monitor” because it can be interpreted in court as an admission of insufficient action or a failure to follow up on a concerning finding. A plaintiff’s attorney can easily challenge the nurse by asking what, precisely, was monitored, when the next assessment was performed, and why a specific intervention was not documented instead of a generic phrase.
The vagueness of WCTM fails to meet the accepted standard of care, which requires documentation to reflect the nursing process (assessment, planning, implementation, and evaluation). If a patient experiences a negative outcome, such as an undetected decline in neurological status, WCTM does not prove the nurse was actively assessing the patient. The note is too generic to demonstrate specific reassessments or required checks. Furthermore, this phrase documents a future action rather than a completed action, which violates the principle of charting only what has already happened to the patient.
Specific Charting Practices to Ensure Patient Safety
Instead of using the vague WCTM, nurses should adopt specific, measurable, achievable, relevant, and time-bound (SMART) documentation. The focus must shift entirely to documenting the current status, the action taken, and the plan for the next specific step.
Documenting Interventions and Reassessment
When documenting an intervention, the note should specify the plan for reassessment rather than charting WCTM. For example, a better entry after administering pain medication is: “Pain level 8/10 reported. Morphine 4mg IV administered per order at 10:00. Plan to reassess pain level and sedation scale at 10:30.” This clearly establishes the nurse’s commitment to follow-up care and provides a time-bound expectation.
Documenting Status Changes and Communication
When a change in patient status is noted, the documentation must reflect the specific parameters and the communication with the healthcare provider. For instance, if a patient develops new chest pain, the note should state: “New onset of 4/10 substernal chest pain reported at 14:00. EKG completed, no acute changes noted. Notified Dr. Smith of patient complaint and EKG findings; awaiting return call for further orders.” This detailed approach provides an accurate, real-time record of the nurse’s clinical reasoning and actions. This level of detail is the strongest defense in any legal or quality review. Furthermore, documenting the specific frequency of monitoring—for example, “Monitoring for change in level of consciousness every 2 hours per protocol”—clearly establishes the ongoing plan of care and the standard being met.